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Delayed blood pressure (BP) and heart rate (HR) decline at recovery post-exercise are independent predictors of incident coronary artery disease (CAD). Delayed BP recovery and exaggerated BP response to exercise are independent predictors of future arterial hypertension (AH). This study sought to examine whether the combination of two exercise parameters provides additional prognostic value than each variable alone. A total of 830 non-CAD patients (374 normotensive) were followed for new-onset CAD and/or AH for 5 years after diagnostic exercise testing (ET). At the end of follow-up, patients without overt CAD underwent a second ET. Stress imaging modalities and coronary angiography, where appropriate, ruled out CAD. New-onset CAD was detected in 110 participants (13.3%) whereas AH was detected in 41 former normotensives (11.0%). The adjusted (for confounders) relative risk (RR) of CAD in abnormal BP and HR recovery patients was 1.95 (95% confidence interval [CI], 1.28-2.98; P=.011) compared with delayed BP and normal HR recovery patients and 1.71 (95% CI, 1.08-2.75; P=.014) compared with normal BP and delayed HR recovery patients. The adjusted RR of AH in normotensives with abnormal BP recovery and response was 2.18 (95% CI, 1.03-4.72; P=.047) compared with delayed BP recovery and normal BP response patients and 2.48 (95% CI, 1.14-4.97; P=.038) compared with normal BP recovery and exaggerated BP response individuals. In conclusion, the combination of two independent exercise predictors is an even stronger CAD/AH predictor than its components., (© 2012 Wiley Periodicals, Inc.)

Exercise testing (ET) stands as one of the most easy, affordable, cost effective, non invasive methods for diagnosing coronary heart disease. Its sensitivity, specificity and prognostic value, especially in the prime era of its implementation in the cardiac diagnostic procedure, is relatively limited. Novel exercise criteria and indices based either on ST segment changes or ST segment independent parameters, such as "Athens QRS score", have greatly improved the diagnostic ability and accuracy of ET. Complex ECG-derived indices linked to ST changes along with the use of right-sided precordial leads have also enhanced the diagnostic accuracy of ET with respect to the extent of ischemic heart disease and the detection of specific culprit vessels. ET contains also a prognostic value, since several ET-derived parameters have been associated with adverse outcome, including ST changes, blood pressure and heart rate response to exercise and duration of exercise., (Copyright (c) 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: Total exercise duration and abnormal QRS score values are treadmill exercise testing (TET) prognostic parameters that have been shown to be significantly and independently associated with cardiac mortality. We evaluated the prognostic value of a new index (M score, Michaelides score) incorporating TET duration and QRS score values in a simple index., Methods: In this study, we included 626 patients, who underwent TET and coronary arteriography. Cardiac catheterization showed the presence of coronary artery disease in 64.3% of these patients. The M score was calculated by adding the value of the Athens QRS score to the duration of TET (in minutes). The outcome measure was a composite of myocardial infarction or death. Patients were prospectively followed for 38+/-21 months (median 36 months)., Results: The composite endpoint was more frequent among the patients of the 1st quartile (M-score values <-5.8). In univariate analysis, mortality of the first-quartile patients was significantly higher (14 vs. 1.1%, P<0.001). In multivariate Cox's regression analysis for age, sex, diabetes, smoking status, hypertension, hypercholesterolemia, maximum ST depression at TET, angina during TET, coronary artery disease on angiography, and echocardiographic left ventricular ejection fraction, the first quartile of M-score values was found to be independently associated with the composite endpoint (relative risk = 3.26, 95% confidence interval = 2.01-5.29, P<0.001)., Conclusion: This study shows that a new index termed the M score, which incorporates QRS score and exercise duration, predicts mortality and occurrence of myocardial infarction at long-term follow-up of high-risk individuals, independently of TET-induced ST-segment changes.

Objective: The accuracy of treadmill exercise testing to detect coronary artery disease is limited in women. This study was undertaken to evaluate whether QRS score can improve the accuracy of treadmill exercise testing in women., Methods: The study population consisted of 114 women with angina-like symptoms, who underwent both treadmill exercise testing and coronary angiography. The impact of QRS score on the standard ST-segment based diagnostic ability of treadmill exercise testing to detect coronary artery disease was studied., Results: Incorporation of QRS score in standard ST-segment diagnostic criteria significantly enhanced sensitivity (from 59 to 80%), specificity (from 40 to 94%) and diagnostic accuracy (from 50 to 87%) of treadmill exercise testing. The QRS score was shown to reduce significantly the false-positive results from 60 to 6%. Furthermore, QRS score accuracy was correlated with the extent of coronary artery disease. The diagnostic ability of QRS score was greater both among patients with normal and impaired systolic function of the left ventricle., Conclusions: QRS score can improve the limited diagnostic accuracy of treadmill exercise testing in women, by predominantly decreasing the high prevalence of false-positive results.

Background: It has been previously postulated that Thallium-201 (Tl201) scintigraphy is characterized by relatively low specificity in hypertensive patients. This study was undertaken to assess any possible influence of false-positive scintigraphic results on the prognosis of hypertensive patients., Methods: The study group comprised 179 consecutive hypertensive patients (128 men and 51 women), aged 50+/-7 years, who underwent exercise Tl(201) scintigraphy and coronary angiography (patients with normal scintigraphic results underwent coronary angiography due to persistent angina-like symptoms). All patients with normal coronary arteries underwent a second Tl201 scintigraphy within 36+/-6 months. Patients with reversible ischemia in the second scintigraphy underwent also a second coronary angiography., Results: Coronary artery disease (CAD) was detected in 78 (44%) patients, while the rest 101 (56%) patients had normal coronary arteries. Abnormal scintigraphic results were revealed in 66 (85%) patients with CAD and in 38 (38%) patients without CAD. Twenty-two (58%) of the 38 hypertensive patients with false-positive scintigraphic results presented reversible ischemia of the infero-posterior wall of the left ventricle. Coronary artery disease was detected in 7 (32%) of these patients during the follow-up period., Conclusions: Hypertensive patients with normal coronary arteries and false-positive scintigraphic results usually present with reversible ischemia of the infero-posterior wall of the left ventricle. This group of patients seems to be at increased risk of developing CAD in a long-term follow-up period.

Background: Ischemic preconditioning (IP) is a cardioprotective phenomenon, induced by brief episodes of myocardial ischemia, which is supposed to affect not only the myocardium, but also the entire cardiovascular system. Considering that patients with coronary artery disease (CAD) have also been described to present impaired aortic mechanical properties, we tried to investigate the possible influence of the late phase of IP on aortic distensibility in patients with CAD., Methods: Fifty patients, aged 48 to 72 (mean, 57+/-6 years), with angiographically confirmed CAD and exercise-induced myocardial ischemia, underwent two treadmill exercise testings (ETs). The second ETs was performed the next day. Thallium-201 scintigraphy was performed during the first and the second ET. Aortic distensibility was evaluated before each exercise testing by a non-invasive technique, using two-dimensional guided M-mode transthoracic echocardiography and arterial pressure was measured simultaneously at the brachial artery by sphygmomanometry., Results: The patients were divided in 2 groups according to the extent of myocardial ischemia at peak exercise of the second test, compared to the first test. In 35 (70%) of the studied patients ischemia signs were reduced during the second ET (Group A), while in the rest 15 (30%) of the patients (Group B) no improvement or even worsening of the observed ischemia signs was demonstrated by the studied exercise parameters and the extent of myocardial ischemia in thallium-scintigraphy. Increased aortic distensibility during the second measurement was found in 33 (94%) of the 35 patients of Group A but only in 1 (7%) of the 15 patients of Group B. Aortic distensibility was found to be significantly improved in patients of Group A, while it was found to be worsened in Group B patients., Conclusions: The aortic distensibility alteration could be used as an index of influence of ischemic preconditioning to exercise-induced myocardial ischemia, which could be considered indicative of the systemic effects of IP in humans.

Background: The aim of this study was to evaluate the contribution of QRS prolongation in the diagnosis of coronary artery disease (CAD) in patients with exercise-induced ST-segment depression exclusively during the recovery period., Methods: The study population consisted of 107 patients (90 males and 17 females) aged 39-70 (mean 59 +/- 7) years who underwent a treadmill exercise test using Bruce protocol and presented ST-segment depression limited to the recovery period. Angiographic data were available for all studied patients., Results: Among studied patients, 74 (69%) were found to have hemodynamically significant CAD, while the remaining 33 (31%) had normal coronary arteries. Concomitant QRS prolongation was revealed in 61 (82%) of the patients with angiographically documented CAD, while in 13 (18%) patients QRS duration remained unchanged. On the contrary, only 4 (12%) of the 33 patients with normal coronary arteries showed prolonged QRS duration during ST depression, while in the remaining 29 (88%) QRS duration remained unchanged., Conclusions: The evaluation of the concomitant QRS duration changes may discriminate patients with truly ischemia-induced ST-segment depression limited to the recovery period.

Objective: To evaluate the improvement of diagnostic ability of exercise testing to detect multivessel coronary artery disease in patients with extended Q-wave anterior myocardial infarction, using additional right-sided chest leads., Methods: Fifty-two consecutive patients with Q-wave anterior myocardial infarction underwent exercise testing, using the standard 12 and the additional right-sided (V3R, V4R, V5R) chest leads, thallium-201 scintigraphy and coronary arteriography., Results: Twenty-one (40%) patients had one-vessel disease, 18 (35%) had two-vessel disease and 13 (25%) had three-vessel disease. The sensitivities of the standard 12-lead exercise testing and its combination with the additional right-sided chest leads were 24% (5/21) versus 28% (6/21) for the detection of one-vessel disease (P: NS), 33% (6/18) versus 83% (15/18) for the detection of two-vessel disease (P<0.05) and 38% (5/13) versus 92% (12/13) for the detection of three-vessel disease (P<0.05), respectively. In thallium-201 scintigraphy, 29 of the 31 (94%) patients with multivessel coronary artery disease demonstrated reversible ischemia. The usual 12-lead exercise testing could detect ischemia in 11 (35%) of these 31 patients, while the addition of the right-sided chest leads could detect ischemia in 27 (87%) of them (P<0.05)., Conclusions: The additional right-sided chest leads significantly improve the low sensitivity of the usual exercise testing to detect multivessel coronary artery disease in patients with previous extended Q-wave anterior myocardial infarction.

Background: ST-segment changes after dipyridamole infusion followed by handgrip isometric stress lack diagnostic value, because of the low sensitivity for the detection of coronary artery disease (CAD). In addition, an abnormal QRS score during exercise had a greater diagnostic ability than ST-segment changes to detect CAD. This study was undertaken to compare QRS score values with ST-segment changes during thallium 201 scintigraphy via dipyridamole infusion., Methods and Results: In this study 128 patients (101 men and 27 women), aged 53 to 72 years (mean, 59 +/- 8 years), underwent Tl-201 scintigraphy after dipyridamole infusion and handgrip isometric stress, as well as coronary angiography. QRS score values and ST-segment changes after dipyridamole infusion and handgrip isometric stress were also estimated. CAD was detected in 96 patients (75%), whereas normal coronary arteries were found in 32 (25%). According to scintigraphic data, 48 patients (37%) had no reversible perfusion defects whereas 80 (63%) had at least 1 reversible perfusion defect. Sensitivities for an abnormal QRS score and ST-segment deviation were 68% versus 18% ( P < .01) for detection of CAD and 75% versus 19% for detection of myocardial ischemia ( P < .01), respectively. Similar specificities were found ( P = not significant)., Conclusions: An abnormal QRS score significantly improves the low sensitivity of ST-segment changes for the detection of myocardial ischemia and CAD by use of Tl-201 scintigraphy with dipyridamole infusion and handgrip isometric stress.

Background: Previous studies have reported that carotid sinus massage responses are associated with advancing age and carotid or coronary artery disease., Hypothesis: This study was undertaken to investigate the potential role of carotid sinus hypersensitivity as a marker for the presence of coronary artery disease, and especially left main stem disease, in patients who were referred for evaluation of chest pain., Methods: Toward this end, carotid sinus stimulation with simultaneous recordings of the electrocardiogram and aortic pressure was performed before coronary arteriography in 150 selected consecutive patients (mean age 59.4+/-9 years) who were referred for evaluation of chest pain., Results: Coronary artery disease was present in 118 patients (78.7%); of these, 35 had single-vessel disease, 35 had double-vessel disease, 33 had triple-vessel disease, and 15 had left main stem with or without such vessel disease. Carotid sinus hypersensitivity was found in 40 patients (26.6%). The incidence of hypersensitivity in patients with single-, double-, or triple-vessel disease and left main stem disease was 8.5, 14.2, 57.5, and 73.3%, respectively. Stepwise multiple logistic regression analysis revealed that left main stem disease was significantly and independently related to the presence of carotid sinus hypersensitivity (p < 0.05). In addition, the presence of hypersensitivity had 73.3% sensitivity, 86.2% specificity, and 96.3% negative predictive value for the presence of left main stem disease., Conclusion: In patients being evaluated for suspected ischemic heart disease, carotid sinus massage responses are related to severe coronary disease. The absence of hypersensitivity may reflect absence of left main stem disease.

Background: Heart rate recovery (HRR) has been identified as a reliable predictor of cardiac mortality, correlated with autonomic tone. In a model of sequential exercise testings, we investigated the reproducibility of HRR and the association between HRR modification and myocardial adaptation to ischemia. Methods: We studied 128 patients (mean age 62 ± 9 years, 83% males) with angiographically documented coronary artery disease (CAD) and a first positive exercise testing, who agreed to undergo a second exercise testing after 24 hours. Results: HRR was increased from 25 ± 10 beats/min at the first exercise testing to 30 ± 13 beats/min at the second exercise testing (P < 0.001). Thereafter, participants were divided into two groups: Group I comprised 88 patients who presented augmentation of the HRR in the first compared to the second exercise testing, while group II comprised 40 patients who presented unchanged or reduced HRR. The rate-pressure product (RPP) at 1 mm ST-segment depression (ischemic threshold) at the second compared to the first exercise testing were significantly improved in group I patients (2345 ± 3429 mmHg/min), while it was worsened in group II patients (−630 ± 2510 mmHg/min) (P < 0.001). Conclusions: In a model of sequential exercise testings, myocardial adaptation to exercise-induced ischemia was associated with favorable modification of HRR. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to investigate the ability of Athens QRS score values to detect stenoses in other coronary arteries than the obstructed ones (which caused the myocardial infarction[MI]) in patients with a history of MI.Methods: We studied 125 patients (93 males and 32 females, mean age 54± 7 years[range 45–68 years]) with a history of MI (46 patients with anterior MI, 54 patients with inferior MI, 25 patients with lateral MI). All patients underwent treadmill exercise testing and coronary arteriography.Results: Athens QRS score values were inversely related to the extent of CAD:−0.5± 0.3 mm for patients with 1-VD (obstructed vessel),−3.4± 2.2 mm for patients with 2-VD (obstructed vessel and stenosis in another vessel), and−5± 1.8 mm for patients with 3-VD (obstructed vessel and stenoses in two more vessels). The ROC curves for the detection of multivessel disease showed that the area under the curve for QRS score values<−3 mm is significantly higher than the curve for ST-segment depression≥1 mm (0.948 vs 0.792, P<0.001).Conclusions: Values of the Athens QRS score less than−3 may distinguish single- from multivessel coronary artery disease in patients with a history of MI. [ABSTRACT FROM AUTHOR]

Abstract: Background: Controversy still exists regarding the impact of new-onset diabetes (NOD) on CV outcomes among patients with hypertension. Our aim was to determine the incidence of NOD in essential hypertensives and to evaluate its association with major cardiovascular (CV) events. Methods: We followed-up for a mean period of 6years 1572 essential hypertensives (mean age 54.3years, 696 males) for the incidence of NOD, as well as of fatal and non-fatal coronary artery disease and stroke. Based on the development of NOD, the cohort was divided into patients with pre-existing diabetes (10%), patients with NOD (10%) and those who remained free from diabetes. Results: During the follow-up period, new or recurrent cases of coronary artery disease and stroke events occurred at a rate of 5.6% (n=88) and 4.65% (n=73). The independent predictors for NOD were age (OR=1.026, p=0.041), waist circumference (OR=1.044, p<0.001), family history of diabetes (OR=2.173, p=0.003) and systolic BP at follow-up (OR 1.022, p=0.044). The presence of NOD was independently associated with greater incidence of stroke (HR 2.404, p=0.046), along with age (HR 1.078, p<0.001), duration of hypertension (HR 1.039, p=0.017) and office systolic blood pressure at follow-up (HR 1.022, p=0.026), whereas development of NOD had no relationship with the incidence of coronary artery disease. Conclusions: Our findings indicate the high incidence of NOD and its close association with stroke in essential hypertension. Poorer control of hypertension appears to be a common denominator of both NOD and stroke in this setting. [Copyright &y& Elsevier]